My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

“Big Med” starts with a visit to the popular restaurant chain, The Cheesecake Factory, and proceeds with his investigation into how it works and works effectively. This chain provides an enormous variety of menu choices, high quality both in terms of ingredients and taste (perhaps not the gourmet’s standard, but really good food), excellent consistency, and reasonable prices. It does not take a huge step to understand the relevant metaphors for health care, and in particular hospital care. Hospitals provide a huge menu of services, and we would all like them to be consistently of high quality and available at a reasonable cost. Unfortunately, they’re not. Gawande searches for how The Cheesecake Factory does it, and comes up with some excellent suggestions for health care.

He starts with the key ideas mentioned above: people should be able to go into a hospital and expect the best care and the best possible outcomes. These should be consistently delivered, and delivered at many locations (not necessarily every hospital for every procedure – to extend the analogy, The Cheesecake Factory has lots of restaurants, but not in every town) and done in a cost-effective way. While with restaurants, each of us knows what we like and whether something tastes good and whether we think we have gotten value for our dollar this is not true for health care. Most people (including physicians outside their own specialty) have little idea of what is quality in medicine. They can tell if they had a good outcome (“I’m better”), but not if it was the intervention that made it better, or perhaps just speeded up – or retarded – natural healing. They can tell if they had a bad outcome (or their survivors can), but not if this was unavoidable. (The current method we have for adjudicating this – malpractice suits – is entirely invalid.) They do not know if their outcome would have been better in a different hospital or with a different doctor or team, or even in the same hospital with the same doctor on a different day. They certainly don’t know whether what they, or their insurer, are paying is appropriate for the value.[1]

Gawande writes that “Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key…We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt. Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them.”

He goes on to describe examples of how American medical care is changing, focusing on the experience of his mother getting a knee replacement at his hospital by a surgeon (not the most famous) who has organized a standardized system for delivering this care, using a (large) team. This surgeon has also accomplished the remarkable (to anyone who knows surgeons) feat of getting all the prima donna orthopedists at his hospital to agree to use the same prosthesis. The principle, just as in the casual dining area, is find out who does it best, identify the characteristics that make it so (removing the chaff and nonsense that may be associated but are just noise, often costly noise), and replicate it.

Applying this principle requires not only standardization, but size. Every hospital cannot be a mom-and-pop store, and the cost savings from scale are what make the whole thing possible. Yes, medical care cannot be completely reduced to recipes, and this can be a real danger. Individual doctors are different, and their skills are different not only by specialty or subspecialty, but in the way they interact with their patients. Some people may like a doctor who is older, or younger; a doctor who is a woman, or a man; a doctor who is more formal, or more casual. Some want a doctor who will explain things to them and elicit their beliefs and desires, and make them the educated “decider”; others want a doctor who is more didactic and authoritative. None of these is the “best” for someone who does not share those values; each is the “best” for those of us who do. The only caveat is when a particular approach actually makes a difference in the health outcomes for all people, not just those who “like” the doctor’s style.

Another danger in size and scale is that many of the processes and procedures that are put in place by these big, standardized organizations do not improve health outcomes, and may even limit them by taking time and energy from the things that do. Management in health care is still very much tied to “Motivation 2.0” (see “Drive”, by Daniel Pink[2], and my comments in The Primary Care Conundrum, August 18, 2012). Many big food, or hotel, or hospital chains do not provide quality, and most certainly do not contain costs; see, for example, “A giant hospital chain is blazing a profit trail”, by Julie Creswell and Reed Abelson in the New York Times August 14, 2012, about Hospital Corporation of America (HCA). Like HCA, “big” is not a panacea, and can be a negative for social values and social justice.

Gawande includes important cautions:

"Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them….

“The vast savings of Big Medicine could be widely shared-or reserved for a few. The clinicians who are trying to reinvent medicine aren't doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates-and that won't be automatic….

"Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?"

I don’t know, but I hope so. Holding on to old ways of doing things when they are not the best (or even very good), or the idea that each doctor can use a different prosthesis and they are all the best, is bad. Devaluing individual workers, whether they are physicians or technicians or cleaners, is bad. Developing ways of delivering high-quality care which is what both individual people and the whole society needs is good.

Good outcomes will certainly not come from the drive to maximize profit. To get truly good outcomes, we must put people and put social justice at the center of any change.

[1] I love this part: “Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens.”

[2]Pink, Daniel H, “Drive: the surprising truth about what motivates us”, Riverhead Books, New York 2009.

Thursday, August 23, 2012

So, two things.
1. I changed the blog template. I hope you like it; I'm not sure I do, but it seems that blogger doesn't actually offer the old one anymore anyway.

2. I still, despite changing my pw and using Google "verify" am getting what I interpret as hacked spam -- items I obviously didn't create appearing in my "draft blog" list. I'll change pw again, but don't know how this is happening, and apparently no one else does either.

Saturday, August 18, 2012

This issue has been one of the recurring themes in the
discussion of health reform, and I have written about it often. People argue
around the edges of the conversation:

·It is not
only primary care doctors that are relatively underpaid; so are many non-procedural
specialists.

·There is
not going to be an increase in the payment to physicians, so higher-paid
specialists are going to have to take less money.

·It is not
just about money; it is about lifestyle. Primary care doctors have to work too
hard.

·It is not
just about money; it is about status. Primary care doctors have lower status.

·It is not
just about money; it is about intelligence. Primary care is just too easy.

·It is not
just about money; it is about unrealistic expectations. Primary care is just
too complex.

And on and on. These are not silly or spurious or even
inaccurate statements, although the last two might be considered another
“primary care conundrum”, the one to which medical students are often
subjected. All of these are things that family medicine and other primary care
specialties have to think about, and address to the extent that it is within
their control. I have, for example, talked about the selecting medical students
who are likely to be more interested in primary care and underserved (both
rural and urban) practice, as well as about making the curriculum more
supportive of primary care. However, it is, ultimately, not the responsibility
of the primary care specialties, or even the medical educators, but rather of the
overall society to develop policies of reimbursement that encourage primary
care – if that is what the society wants and needs.

Thus “Payment
reform for primary care within the Accountable Care Organization”,[1] by
Goroll and Schoenbaum in the August 8, 2012 JAMA
is appropriately subtitled “A critical issue for health system reform”. While
it may not really be all about the money, a good part of it certainly is. One
doesn’t have to be an economist who believes that everything can be reduced to, or expressed in terms of, money, to
recognize that lifestyle and status are just other manifestations of
money. If you make more (or, more to the point, if the services that you render
are reimbursed at higher levels), you can work (if you choose) less, or a
health system employing you can hire more people to do that work. Status is
measured by many yardsticks, but most of them, at least in our society (since
we do not have inherited titles) have to do with money.

Goroll and Schoenbaum, from, respectively, the Massachusetts
General Hospital and the Josiah Macy, Jr. Foundation, focus their discussion on
Accountable Care Organizations, or ACOs. These are a centerpiece of the health
reform law (ACA), but most experts believe that, whether ACA survives or not
(it has survived the Supreme Court, but there will be continuing challenges,
particularly if the Republican Party takes the Senate and/or White House in
2012) it is the wave of the future. This is because it is both a framework for
increasing quality and for saving money; saving money is the main thing that virtually
all politicians and pundits talk about in regard to health care. Even providers
do so, although they mostly focus on saving it on other aspects of the health
system.

In a sense, this last is what ACOs seek to avoid; by
assigning patients to an ACO that provides comprehensive care – ambulatory,
hospital, post-hospital – for lives
(in insurance parlance) or people (in
English) it seeks to avoid “blaming the other”:

·We took
good care of them, but when they went to the hospital they received poor care
or unnecessary procedures.

·The “local
doctor” didn’t provide adequate care, but luckily we in the hospital could save
the patient.

·We did
great care in the hospital, but the nursing home (or patient’s family) didn’t,
so the patient suffered, or had to be readmitted, or died.

·They
discharged the patient – home or to the nursing home – too soon, so despite our
excellent care the patient suffered, or had to be readmitted, or died.

The devil, as always, is in the details. How will this be
different from the managed care of the past? (“I heard this all back in 1995,” says a colleague.) In order to
avoid some of the politically unpopular characteristics of “managed care”, the
ACA does not contain a requirement that patients receive care only from the ACO
to which they are assigned. However, if they are cared for elsewhere, how can
the ACO ensure either the quality or the cost? Who will care for the uninsured?
How will (and they will)providers
(including hospitals, doctors, nursing homes) game the system to maximize their
advantage by passing the buck, cherry picking the relatively health,
emphasizing high-reimbursement and de-emphasizing low reimbursement care? How
will (and here “Will it?” is still a question) that be rectified?

The important point of the JAMA article is made in the beginning: that “Primary care, the foundation of the ACO, requires payment reform to
enable and make durable its transformation into a high-performance model such
as the patient-centered medical home.” Primary care is the foundation of the ACO, just as it is the foundation of any
effectively-functioning health system. The authors cite 3 main obstacles to
increasing payment for primary care: 1) Inertia.
It is not the way our incredibly elaborate and expensive payment system is
currently structured, and changing it will be hard; 2) Resistance. The development of new systems and funding will
require, particularly in a setting in which overall funding will not
appreciably increase, the reallocation of money from one set of groups to
others, and this certainly will (and already has) meet with resistance by those
who will lose money. 3) “Motivation 2.0”. “…many health care
executives (including some physician managers) believe that physicians work
harder under fee for service and that productivity is at risk of faltering
under payment systems that do not maintain a strong, volume-based incentive.”

The first two are obvious and will have to be strongly and
persistently addressed if there is to be any success in re-engineering the
health care system; there is no one who will fight so hard as a group whose
privileges, no matter how unfairly earned, are being threatened. However, the
third is more questionable. Another colleague asked “is there any evidence that
this is not true?” Indeed, there is some evidence that it is; in the 1990s when
hospitals and health systems bought out physician practices, they often found
that the physicians, now salaried, were less productive than when they were in
practices where their income came from productivity. The flaw there is that the
same standards were being used for measurement: how many patients were seen,
how many wRVUs (a measure, albeit imperfect, of physician productivity). It was
not measured by whether the quality of patients’ health was improved. Perhaps
by seeing fewer patients-per-day, for longer visits when they need them, or
providing care in teams and by phone and email when appropriate, fewer return
visits would be needed (bad if reimbursement is all fee-for-service) and
delivered in teams.

Goroll and Schoenbaum do not, actually, use the phrase
“Motivation 2.0”. This comes from Daniel H. Pink, a business management author,
from his book “Drive”, published in 2009 and one of the most influential
management books in recent years.[2]
Pink contrasts the management style based on this sort of motivation (2.0, not
the “1.0” that was ancient man’s – survival), the dominant one of the 20th
century and into the 21st with a new understanding of what motivates
people and what kind of management is most effective. He draws on decades of
psychological and sociological and business research, as well as actual
implementations in management practice, to clarify what this new appreciation, “Motivation
3.0” is. I recommend reading the book, quite short and easy.

But understanding and implementing effective motivational
practices will certainly not, in itself, solve health care. Making sure that
there are systems to ensure quality, and that they are available to everyone,
is the sine qua non.

Friday, August 10, 2012

An op-ed by Sanjay Gupta, MD, the Atlanta neurosurgeon and
CNN medical correspondent, appeared in the New
York Times on August 1, 2012. “More
treatment, more mistakes” makes the case that medical errors are common and
that they are largely due to the pressure to “do more”, to do more tests, to do
more x-rays, to do more surgery. This is not news in itself; the Institute of
Medicine (IOM) of the National Academy of Sciences published its study “To
Err is Human” in September 1999, observing that between 44,000 and 98,000
deaths occurred per year as a result of medical errors (full text available at http://www.nap.edu/openbook.php?isbn=0309068371).

To Err is Human itself was not the beginning of the
study of medical errors. It uses a taxonomy dividing errors into “Diagnostic”,
“Treatment”, “Preventive” and “Other”, published 6 years earlier in a study by Lucian
Leape, et al., in the Quality Review
Bulletin.[1]To Err is Human detailed the variety of types of medical errors that
could occur, the relative frequency with which they occurred, and the reasons
why they occurred, and provided suggestions as to how to prevent them from
occurring. The Institute for Healthcare
Improvement (IHI), founded by Leape and former CMS director Don Berwick (who
were among the authors of the IOM report) has been working on this issue for
more than 25 years. Its “100,000 lives campaign” sought to save that many lives
by having hospitals sign on to implementation of certain strategies that had
been shown to reduce errors. These included “timeouts” in surgery to be certain
that everything was correct (right patient, right part of the body, etc.)
before beginning, particular ways of managing people on breathing machines in
intensive care units to prevent “ventilator associated pneumonia”, and the
like.

A key point is that very few of these errors are intentional
– they are not malpractice in the traditional sense, they are rarely the result
of physicians being “bad doctors” – and yet people, avoidably, die from them. A
key part of the strategies promulgated by people like Berwick and Leape, IHI,
by the IOM report, and others working in the field is to employ the systematic
approach to error reduction developed in other industries, such as airlines. (A
common trope is that if airlines had errors as frequently as medicine, a jumbo
jet full of people would be crashing several times a day.) Continuing
follow-ups have looked a “how we are doing”, such as in “Five years after ‘To
err is human’: what have we learned?” by Leape and Berwick in JAMA in 2005[2]
and the summary of it by the Commonwealth
Fund.

It is in the context of this history that Gupta’s article
appears. Its main significance is that it brings to public (New York Times) attention the fact that
these problems still exist, and that despite progress (and there has been much)
there is much that still needs to be addressed. It is a balanced presentation,
but does emphasize the point in the title – that more treatment leads to more
errors, or, to put it another way, that more
is certainly not always better. He cites “Rule #13” from the novel “House of
God”, written by Stephen Bergman, MD (under the pseudonym Samuel Shem) in 1979:
“The delivery of medical care is to do as much nothing as possible,” a
restatement of the dictum primum non
nocere, first do no harm.

An interesting series of letters responding Gupta’s paper
appeared under the heading “Taking
steps to reduce medical errors” in the Times
on August 4. One of them is from Bergman, who echoes Gupta’s concept that
fear of malpractice suits (the “whining motor behind doctors’ ordering
unnecessary, pricey tests,”) is the cause of many errors, and applauds
interventions such as surgical time outs. However, another letter, from Niall
O’Dowd, the uncle of Rory Staunton, the 12-year old boy who died after being
treated for a “minor” scrape in the NYU Hospital emergency department (see Jim
Dwyer, “An
infection, unnoticed, turns unstoppable”, NY Times July 10, 2012 and many follow-up articles including a
column by Maureen Dowd “The
boy who wanted to fly”, 3 days later), points out that there are also
dangers, as in his nephew’s case, from doing too little.

Mr. O’Dowd focuses, naturally, on the emergency department,
which is where his nephew was treated, inadequately as it turns out. Emergency
departments are seeing more and more patients, and are responsible for a very
large and increasing number of admissions to hospitals, as detailed in a recent
New England Journal of Medicine article
by Schuur and Venkatesh, “The growing role of emergency departments in hospital
admissions”.[3] They identify a number of trends that tend to
increase the use of the emergency room as a source of care, particularly for
acute conditions. These include the lack of availability of acute-care
appointments in primary care practices, and the lack of the high-tech
instruments such as CT scanners that permit EDs to rapidly diagnose and admit –
or rule out and then discharge – conditions such as heart attack and
stroke. They also include public education
campaigns that urge people to go to the ED when they have symptoms that could
be heart attack or stroke, and, of course, the fact that lack of insurance
prevents people from accessing health care in most other settings (federal law
requires EDs to assess anyone who presents there). While the fact that the
increase in admissions from the ED may have something to do with their “lower
threshold” (“…emergency physicians are
trained to assume the worst and are more likely to admit patients with
uncertain diagnoses and with whom they don't have an ongoing relationship, and
that they are unwilling to discharge patients when they cannot guarantee
outpatient follow-up,”) it is also possible that in their pressure to
diagnose and admit the most sick, they could possibly undertreat some, like
Rory Staunton, who do not appear to be so ill.

Mr. Staunton may have benefited from antibiotics he did not
get. Other letter writers speak of both the dangers of underusing antibiotics
and overusing them; however, the settings they describe (critical care units in
the first case, treating viral syndromes in the second) are very different. Doing
a lot is not necessarily wrong, or right. Doing little is not necessarily
wrong, or right. Both can cause errors, and both can save lives. Yet a fifth
letter writer suggests “our mission is clear: if it’s right for the patient,
it’s the right thing to do.”

This is true as far as it goes; the difficulty is in
ensuring what is right for the patient. But systems, checklists, timeouts, and
consistent rules can go a long way to making this be the case. And if people
with non-acute, non-emergent conditions can get in to see their doctors, and as
important, have doctors and can have
the health insurance that allows them to be seen, it would help even more.

This is something that we must not lose sight of; as Schiff,
Bindman, Brennan et al note in a 1994 JAMA article, denial of care is the
“gravest of all quality defects.”[4]

Thursday, August 2, 2012

.The lead article in the New York Times (right column, front page, by Annie Lowrey and Robert Pear) on Sunday, July 29, 2012, has the provocative headline “Doctor shortage likely to worsen with health law.”My first instinctive reaction was “What? I don’t know of any part of the new health law, the ACA, that will reduce the number of doctors!” Then, reading the first sub-head, I realized what they meant. “Primary care is scarce”, something I well know and have written a lot about, and then, in smaller type, “Expanded coverage, but a greater strain on a burdened system.”

What they are saying is that the shortage of physicians, especially primary care physicians, will effectively increase (get worse) as millions more people gain insurance coverage under ACA. This will happen both through expansion of Medicaid coverage or through health insurance exchanges that will permit both individuals and small companies that have not previously had or offered health insurance to buy it at much lower rates. The expansion of health insurance coverage to these groups is a good thing; it will eliminate a major barrier to quality health care, itself a component of good health. Unfortunately, phrasing the problem in the way that the NYT headline does is likely to inflame displeasure with the law among those who, through ignorance or selfishness or both, are happy to draw up the bridge behind themselves, not wishing to share their, often limited, access to doctors with the newly insured. Surely, this is not an acceptable reaction.

The problem is that there are too few doctors to provide each person with full access to care, especially in an aging population because, as noted in a quote from Dr. Darrell G. Kirch, president of the Association of American Medical Colleges (AAMC) “Older Americans require significantly more health care…Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.” It is, however, much more about the poor distribution of doctors by specialty (too few primary care physicians, too many of many varieties of subspecialists), by geography (too few in rural and poorer areas, too many in more affluent and suburban areas), and by the insurance status of the patients that they care for (too few who take Medicaid, and even Medicare, and too many willing to care for only those with insurance that reimburses more). And, relevant to the cost of care, too many whose business model is built upon doing high-cost, high-profit procedures even when they are marginally (or not at all) beneficial to the patient, rather than providing the comprehensive care needs of people.

Sadly, and for the wrong reasons, some of this may not come true, so some of the fears of the already-insured may be mitigated. Many states have indicated their plans to not participate in Medicaid expansion despite the financial incentives to do so (the federal government will pay 100% for the next several years, and 90% thereafter). These same states, as well as others, also pay so little under Medicaid that many doctors won’t see Medicaid patients. Unfortunately for that ignorant-or-selfish-or-both minority of seniors who say “keep the government’s hands off my Medicare!”, many of those same doctors are now refusing to accept Medicare patients. Hey, if they can make a big living without it, why should they take care of your mother? So if you are not on Medicaid OR Medicare maybe you’re safe – if you live in a relatively affluent part of an urban area, and have private insurance, and especially if you are in an integrated health system such as Kaiser that provides a strong primary care base.

The NYT article indicates that “Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.” In fact the gap is much greater than that between primary care physicians and specialists “like orthopedic surgeons and radiologists”; it can be several times greater. (This is because “specialists” includes, in addition, doctors like psychiatrists and some pediatric and medical subspecialists who earn much closer to what primary care doctors do, and thus bring down the “specialist” average.) A recent estimate was that an anesthesiologist can anticipate earning $7 million more in a career than a family physician!

I woke the other day to NPR to hear Republican senator Orrin Hatch saying “To be clear, it is a disgrace that so many American families go without health insurance coverage.” I was nearly ecstatic; to agree that something is a problem is the first step to getting together to solve it. And, surely, that something is “a disgrace” is even worse than being a problem. I turned up the radio to find out how Sen. Hatch and the Republicans were going to solve it. Unfortunately, that was not to be. It was a sound bite in a story by Julie Rovner titled “GOP Says Coverage For The Uninsured Is No Longer The Priority” (July 27, 2012). I hadn’t known it ever was a priority for the GOP, but this piece laid any doubts to rest. Worse than the double-talk from Hatch was Senate majority leader Mitch McConnell, in this excerpt:

McConnell: "Let me tell you what we're not going to do. We're not going to turn the American health care system into a Western European system. That is exactly what is at the heart of Obamacare. They want to have the federal government take over all of American health care."

By "Western European," McConnell means government-run or primarily government-run. Western European countries also pretty much don't have people who don't have health insurance. And by the way, there are closer to 50 million Americans without health insurance; 30 million is the number the health law is estimated likely to cover.

McConnell never says what the GOP is going to do, but you can be sure it will not have anything to do with covering everyone. This is too bad; there are possible solutions, and many of them are even based in the marketplace. Step one is for Medicare to completely revamp its reimbursement policies. This is because, to a large degree, Medicare reimbursement is the basis for all insurance reimbursement; while they may pay more (say, 1.5x Medicare) the ratios are the same, so if Medicare changes what it reimburses for primary care relative to subspecialty care, other insurers will follow.

In biological systems, the normal situation is to have “negative feedback loops.” For example, if the thyroid gland is producing enough thyroid hormone, it shuts down production in the pituitary gland of another hormone that stimulates the thyroid. When there is not enough thyroid hormone in the blood stream, the low levels stimulate the pituitary to become active, activating the thyroid gland. This is functional. Imagine how dysfunctional a “positive feedback loop” would be – the more the thyroid produced thyroid hormone, the more the pituitary would produce its stimulant, creating yet more thyroid hormone, and soon we’d all be hyper-thyroid and dead!

This is like the current medical reimbursement system. We pay doctors more to do procedures, pay them more to take care of only a few diagnoses in a limited organ system, pay them more if they live in an expensive area, and even more if they refuse to care for those on government insurance. This is a positive feedback loop where you economically do the best being a medical “partialist” in a nice suburban area taking care of relatively well-off people, and worst being a generalist in a rural area taking care of people who need it. Or, if you choose, work less than full time and still make a good living.

Medicare should immediately begin reimbursing primary care at a higher rate, including for the effort and cost of managing chronic disease, so that the income differential between generalists and specialists largely disappears. Then it should increase payments for doctors working in more rural and remote areas, not for “desirable” urban and suburban areas. Doctors practicing in urban underserved areas should get smaller incremental payments (after all, they can live in a “good” neighborhood and commute).

We will still have a shortage of doctors until the pipeline fills, but such a system will decrease the financial impetus to be yet another subspecialist in a metropolitan area that already has enough, and increase the impetus to become a generalist in an underserved area. If we are to depend on the market, this is the kind of market-based approach we need.